A new picture of quality medicine.

Norman Rockwell never painted a picture of a personal computer, but perhaps he should have.

In 1929, Rockwell summed up the Americans looked at physicians in a famous illustration for the Saturday Evening Post. The picture shows a kindly pediatrician auscultating a girl's doll with an old-fashioned stethoscope. A saccharine image today, perhaps - but one that captured the wisdom, wit, and warmth of the era's family doctor.

In the age of managed care, many people believe these virtues - like the Post - are extinct. Medical informatics, the lifeblood of cost-efficiency, has come to symbolize the demise of "quality." Critics claim the patient has been reduced to a Social Security number and a CPT-4 code.

You can hardly blame them. Early information systems for physicians concentrated on billing and insurance claims. Clinical information systems revolved around the all-encompassing electronic patient record - a laudable goal, but one that has done little so far to enhance patients' health. No wonder the public and much of the medical community are skeptical about the potential of informatics for improving the quality of care.

However, medical informatics today mean that cost-efficiency and high-quality medicine are not mutually exclusive. As physicians consider information systems that will help them meet the demands of managed care, they should not lose sight of this fact. Many of the software features designed to help physicians operate more cost-effectively will also help them practice better medicine, reduce malpractice risk, and restore a personal connection to patients. These benefits become particularly important as practices expand and network; information systems can provide a "virtual" continuity of care that might otherwise be jeopardized.

Reaping these benefits, however, means choosing a "next generation" information system - one that is not confined to billing and claims, or an electronic patient record. it's up to the physician executive to make an informed choice: Look for systems that truly integrate (not merely interface) managed care components, clinical capabilities, and other features in a model that mimics the workflow of an actual practice. Take the time to learn about the technology. Consider how a vendor's product will work at every point within your organization.

In our experience developing an information system for the Orlando Health Care Group and other multi-site physician practices, the following have emerged as critical features that physician executives should consider in their decision-making.

I. Integrated registration

An information system should capture relevant demographic and eligibility information about each patient, and distribute this data to other application components for users who require it. For the practice, integrated registration reduces the chance of multiple charts, and the consequent danger of inaccurate or incomplete information. For patients, integrated registration means better customer service - for example, quicker intake at the front desk and quicker check-out at the cashier.

2. Problem-oriented medical record 

Problem-oriented systems link and display notes, diagnoses, and results of tests, procedures, and therapies associated with a patient's specific health problem. These systems allow physicians and other clinicians to easily assess the patient's progress and course of treatment across an entire episode of care. As practices grow larger and more patients are seen by interdisciplinary clinical teams, this perspective is becoming essential to high-quality medicine.

3. Clinical templates

Clinical templates serve as quality control checks, ensuring that physicians and their staffs don't overlook important subjective and objective data when presented with a specific illness. Often, the templates take the form of an embedded prompt or a dialogue box. Unlike an electronic record, template-based systems are interactive, stepping physicians through questions that may help verify a diagnosis - and reduce the risk of error.

4. Clinical alerts

Think of these as electronic "sticky notes:" online reminders that follow a patient throughout the practice. As patients pass from one provider to another, these alerts ensure that essential information, such as notes on drug allergies or contraindications, is immediately presented.

5. Health maintenance cues

Rockwell's physician knew his patients and could anticipate their needs. But he didn't have to contend with today's complex schedules of immunizations, tests, and preventive procedures. An information system should help a provider organization's staff think ahead by providing proactive cues to schedule health maintenance.

6. Disease management cues

As new protocols are developed for the treatment of chronic disease across an entire population, information systems should be able to help integrate these protocols into day-to-day patient care. For example, suppose an academic society developed new recommendations for drug therapy and lab work in treating ulcer disease. A large, multi-specialty practice adopts the guidelines, but how does it get the word out to all its physicians? One answer: When an ulcer patient arrives for an appointment, the information system might include a "pop-up" window that immediately informs the physician that a new guideline exists. The system would walk the physician through the recommendations, and a new or revised clinical template for managing the patient. By quickly being able to change the way a large number of physicians practice, the group is more responsive to patients, and can better begin monitoring outcomes of the new protocol. These information systems should be "table-driven," allowing new rules for treatment to be easily embedded into the clinical templates.

7. Messaging

Internal communication is critical in today's large physician practices. However, given their increasing complexity, they require more than stand-alone e-mail systems. Practices should choose information systems that seamlessly integrate messaging with other interactive applications so that the message content facilitates day-to-day work processes. For example, with a next-generation system, a physician might review a lab test by clicking a mouse, attaching the data to a progress note that is then sent to a colleague, and then "dragging and dropping" the result into a nurse's in-basket with instructions for contacting the patient.

Remember that next-generation features like these should support your practice, not the other way around. If you and your staff have to significantly alter the way you work in order to take advantage of the latest software package, something's wrong. Ultimately, the criteria a physician executive must consider are not the bells and whistles, but whether a system allows an individual practice to perform better medicine.

Key Concepts: Medical Informatics/

Next-Generation Information

Systems/Managed Care/Quality

It's up to the physician executive to make an informed choice when selecting a "next-generation" information system Look for systems that truly integrate (not merely interface) managed care components, clinical capabilities, and other features in a model that mimics the workflow of an actual practice. Take the time to learn about the technology. Consider how a vendor's product will work at every point within your organization. Seven critical features that physician executives should consider in their decision-making are described.